PI Objective and Calculation
MIPS eligible clinicians must attest to having conducted an annual self-assessment using the High Priority Practices Guide, at any point during the calendar year in which the performance period occurs.
This measure is required but will not be scored. An attestation of 'yes' or 'no' will not affect the total number of points earned for the Promoting Interoperability performance category.
Promoting Interoperability Discussion
ONC developed and released the Safety Assurance Factors for EHR Resilience Guides (SAFER Guides) in 2014, and later updated them in 2016. This series of nine user guides support the ability of health care providers to address EHR safety. Collectively, the SAFER Guides help health care organizations at all levels, from small practices to multi-system chains and tertiary care facilities, to conduct self- assessments which optimize the safety and safe use of EHRs in the three areas:
- Foundational Guides
- Infrastructure Guides
- Clinical Process Guides
Video guide: https://www.youtube.com/watch?v=LxQE6MdDZwY
While this measure is not scored, as stated in the 2022 Quality Payment Program Final Rule: CMS believes "...that requiring MIPS eligible clinicians to periodically review this self-assessment would support a stronger culture of change management within organizations, and would assist organizations in actively understanding and addressing potential safety vulnerabilities, which may significantly impact an organization’s safety posture."